86 Telepractice: A Clinical Guide for Speech-Language Pathologists
the best placement of the computer and any lamps or lights. Make
sure that visual distractions are limited. If there is a window that the
client is facing, this may be a distraction if it is facing a busy street or
playground or a construction site. Inside the room, it is also important
to limit visual distractions such as bookshelves, toy shelves, or a televi-
sion. The clinician also needs to be cautious about visual distractions
on their end. The clinician’s background should be devoid of anything
that might be distracting for the client.
When scheduling an assessment, the SLP should have a discus-
sion with the client and family members in order to confirm that
the client is sitting at a desk and in a chair that is appropriately sized
so that the seat allows the client to have both feet on the floor. For
younger children, the chair should not swivel, as it may be distracting
for the client and clinician. An appropriately sized desk and chair will
also allow the client to focus on the task at hand and easily access
the computer when needed to respond to a clinician’s question or to
point to an item on the screen. In the conversation with the family,
the SLP should ensure that the camera placement will be adequate for
viewing the client’s face, as this is important in determining speech
sound production, and morphological endings, among other aspects
of communication.
Prior to starting an assessment, both the client and clinician need
to confirm that all equipment (e.g., computers, audio, camera, etc.)
are in working order. internet speeds should be appropriate to support
the videoconferencing platform, as well as the bandwidth needed to
screen share the actual assessment booklets. Doing a speed test a few
days prior to the evaluation, in addition to a quick check immediately
before the start of the evaluation, is crucial to guarantee the speeds are
adequate to perform the evaluation. As noted earlier in this chapter,
the facilitator, whether it is an individual hired by a school district to
be with the clients or a family member, should be adequately trained
to support the client and clinician during the assessment. It is imper-
ative that the facilitator (or eHelper) be trained and understands that
they are not to cue the client in any way to ensure a smooth evaluation
during the formal assessment procedures.
Once the environment is set up to support an evaluation, the SLP
should obtain informed consent. This may be verbal or in writing,
4. Assessments, Evaluations, and eHelpers 87
depending on the state laws and the setting in where the client receives
the service. Many school districts, whether required by law or not, will
require caregivers of minors to sign an informed consent document.
Private practices often obtain written consent as well at the time
the evaluation is scheduled. Always check state licensure laws, the
state education code, as well as any other regulatory bodies that may
have jurisdiction over SLPs, as these will vary from site to state and
state to state. A parent/caregiver questionnaire should also be given
to the client and family to complete prior to the evaluation. The ques-
tionnaire can be sent via e-mail or post office or could be completed
via an interview with the family, including the client. Information
collected prior to the evaluation will assist the SLP in determining
strengths and weaknesses of the client, along with the caregiver and
client’s hopes for the future communication success. Knowing which
skills are important to the family and client will assist in planning a
successful evaluation. An interview will also give SLPs insight into
the family dynamics and what is important to them regarding the
client’s communication abilities. Interviews or questionnaires may
also be obtained from other stakeholders such as teachers, other
professionals such as the occupational therapists, physical therapists,
or psychologists. This assists the SLP with getting a well-rounded
picture and knowledge of client’s strengths and weaknesses, as well
as the variability of these within different settings. Figure 4–3 shows
a preassessment checklist.
Standardized Assessment
Once the environment is set up to accommodate the client in what-
ever setting (home, school, clinic, etc.) and an interview has been
completed, the next step is to determine what formal and informal
assessment measures will be used. The choice of assessments for the
telepractice model is similar to the in-person model, and is deter-
mined based on an interview with families and any other involved
with the client. Formal tests should be chosen and then determined
if they are available in a digital or electronic format. The SLP needs
Figure 4–3.
Preassessment checklist.
88
4. Assessments, Evaluations, and eHelpers 89
to obtain access to the digital versions and ensure they are compatible
with the internet browser and the videoconferencing platform. On
occasion, some digital test booklets might work better on one browser
than another. This information is typically contained in the online
instructions for administering a test.
The next step is for the SLP to ensure that the digital materials
or picture books are set up in an easily accessible manner so that they
can move quickly from one picture book to the next, as needed. Know
where each subtest is located within a digital folder and ensure they
are organized for ease of administration. Administering a test online
is somewhat different from an in-person administration in that the
picture books are on screen, and the instructions are typically in a
different folder. If the SLP uses a two-screen setup, (computer screen
plus a 2nd monitor), then the instructions can be on one screen for
the SLP to see, and the picture book is on another screen to share
with the client. If only one screen is available, the clinician can use a
split-screen setup on the single screen. The SLP must practice until
they are comfortable managing the online assessment as easily as they
do in-person, moving from one picture book to the next with ease
and doing so smoothly. Practicing administration of tests cannot be
emphasized enough, just as SLPs do when learning a new test. Prac-
tice with other clinicians, with friends, with family members until
one’s confidence is commensurate with in-person administration.
Each participant, including the clinician, client, and facilitator,
needs to wear a headset with a microphone. The microphone and
the headset will facilitate the client hearing the instructions more
clearly, and the clinician accurately hearing the responses. This is
essential for accurate transcription of client answers. Recording the
evaluation may be useful for later listening to double-check the accu-
racy of clinician transcription. It is also possible for the facilitator to
audio record the client on a phone that can be uploaded to a shared
folder in the cloud for the SLP to double-check the accuracy of the
client’s responses. Recordings should be deleted once the tests have
been scored.
SLPs must continue to follow standardized instructions for each
test they administer. Any deviation from these standardized instruc-
tions must be noted in the assessment report. If there are connection
90 Telepractice: A Clinical Guide for Speech-Language Pathologists
issues during the testing, these must also be noted, particularly if the
instructions are repeated due to the poor connection. SLPs must also
determine how they might modify the client’s responses to receptive
tasks, such as when a client is asked to point to a picture or series of
pictures on the screen. Wood et al. (2021) noted that if shared mouse
control is possible, the client may hover the cursor over the correct
picture or use the annotation tools to circle or place a stamp on their
answer on the screen. If the responses are numbered on the picture
book, the client could state the number of the picture.
During the assessment, the SLP should ensure that the client
understands the directions by using various techniques, such as
having the client repeat the directions back to the clinician or using
visual cues. When changing picture books via screen share, clinicians
should check with the client as to what they are seeing to ensure that
they are seeing the correct page in the stimulus book. Asking the
client to repeat back clinician instructions is another means to check
on comprehension.
If a client needs breaks, the SLP should plan these between sub-
tests or tests. Short breaks can include a movement break (e.g., stand
up, engage in some movement, etc.), tangible reinforcements (these
can be on screen or sent ahead of time), or the use of a visual schedule.
The types of breaks chosen for each client will depend on client need
and should be determined prior to the start of the assessment during
the interview process so that a plan is in place and the break schedule
can be shared with the client prior to the start of the session.
Prior to starting the assessment, the SLP should determine how
to proceed if the internet connections become poor or lost entirely
during the assessment. Whether an item is repeated or eliminated
will depend on the standardized instructions and whether or not
repetitions are allowed. If they are not, then the SLP should have
predetermined how to handle poor connectivity that interrupts the
administration of a subtest.
Establishing rapport at the beginning of the assessment is crit-
ical to the successful completion of tests. Talking with the client and
family to get to know them either at the beginning of the session or
in an informal session prior to the day of the evaluation is important
in engaging the client. Establishing rapport online is very similar
4. Assessments, Evaluations, and eHelpers 91
to in-person sessions. Keep in mind that the initial “getting to know
you” session may go quite well, but the first evaluation session might
begin to fall apart if the client has a bad day. The SLP should be
prepared to switch to informal assessment (e.g., language sampling,
etc.) if the client is not ready, willing, or able to complete it in a stan-
dardized manner. Rescheduling, if possible, is better than trying to
engage a client who is not ready for testing. Figure 4–4 shows an
assessment checklist.
For bilingual clients, determining which language is their primary
language is crucial to a successful assessment. It is also important
to determine whether the client needs to be assessed in both lan-
guages to ensure that there is a language disorder. The matching
up of bilingual clinicians with bilingual clients who speak the same
language makes for an ideal situation. Obtain consent to use an
interpreter if needed and make sure it is obtained prior to the start
of the assessment. With bilingual clients, ASHA (n.d.b) notes that,
“given the complexities involved in bilingualism and the significant
variabilities among the linguistic skills of multilingual clients, clini-
cians must be prepared to address the unique situation of each client.”
Assessment tools may vary from the standardized assessments that
are used with monolingual English-speaking clients. Often, it is diffi-
cult to find standardized assessments for many languages other than
English. Therefore, it would be useful to use dynamic assessment,
criterion-referenced assessment, or other alternative means to obtain
a descriptive analysis of the individual’s strengths and weaknesses
relative to a group. Using cultural and linguistically adapted tests,
when available, are appropriate.
Language sampling in a telepractice service delivery model
is doable but takes some thought and planning. The SLP may use
photos and drawings available online or scanned from appropriate
sources. Finding out the client’s interests in advance will facilitate
the selection of appropriate photos or drawings that are familiar to
the client. Asking the family or caregiver for photos of places the
client has visited and family photos are useful as well. In addition,
videos available on YouTube may also be used for language sampling.
Showing the client a short video, then asking them to retell the story
would work as a means to obtain a language sample. Asking about
92 Telepractice: A Clinical Guide for Speech-Language Pathologists
Figure 4–4. Assessment checklist.
a recent movie or television show they have seen works for school-
age clients and older. Having the client talk about a book they read
recently or something they have done within the last few days will
elicit a language sample for analysis.
4. Assessments, Evaluations, and eHelpers 93
For younger clients (under age 5), having them describe their
favorite room in their home or school will typically elicit language.
Younger clients may also be able to tell the SLP about a favorite book
or a trip to the park or other vacation spot. Wordless books are a great
resource for shyer clients. Many of these wordless books are available
on websites that sell books or offer digital subscriptions. If rapport
was established prior to or at the beginning of the evaluation session,
then eliciting a language sample is not too different than obtaining
one in-person.
Observations of school-age clients are often a hurdle that needs
to be overcome because it is difficult to imagine how an SLP can
observe a client in their classroom remotely. There are at least two
ways this could be completed, but both would require permission
from school personnel (principal, classroom teacher, or special edu-
cation administrator) to be accomplished. If there is a facilitator that
is being used for teletherapy on the school site, then the facilitator
can use a smartphone to film the student while engaging in a whole
classroom activity or a small group activity within the classroom. The
activity will need to be carefully chosen to include one that the student
typically engages in readily. Once the facilitator completes the video,
it should be uploaded to a secure folder in the cloud for the SLP to
view and make notes. The second way to complete an observation
would be to do it live with the facilitator using FaceTime or other
off-the-shelf platform with the SLP or both of them logging into a
videoconferencing platform and placing the computer or tablet in
front of the student that is being observed. This second option (video
conferencing with the device on the student’s desk) is less than ideal
because it may be difficult for the SLP to hear what the teacher or
other student is saying, or in relationship to their client. Setting up
either of these options, either videotaping or live observations, takes
some planning and coordination as it needs to be done well in advance
of the actual observation. All stakeholders must be on board for this
to be successful. Early on in telepractice, some SLPs skipped direct
observation of the client in favor of interviewing stakeholders such
as teachers, occupational therapists, or psychologists. Although this
information is helpful, it may not be equivalent to the SLP completing
a direct observation. The SLP will certainly obtain good information
94 Telepractice: A Clinical Guide for Speech-Language Pathologists
from stakeholders with interviews, but the SLP might not have the
opportunity to see the client through their own lens.
For clients not in school (early intervention, adult rehabilita-
tion clients, etc.), having family members video record the client in
conversation in a variety of settings (home, favorite activity such
as playing cards, having coffee with friends, etc.) should suffice in
obtaining a language sample.
Modifications
As noted previously, modifications may be made to the assessment
procedures or standardized instructions, but they must be noted and
described in the report.
Report Writing
Reports for evaluations completed via telepractice will look like the
typical report completed in-person. The report will include the fol-
lowing sections:
1. Reason for evaluation: This a short paragraph regarding why
the client was referred.
2. Background information: This information is derived from
the initial intake interview and includes any important medical
information.
3. Interviews with teachers (if the client is school age) and other
stakeholders: These describe the findings from the interview
and any relevant information that relates to student perfor-
mance, including why the client was referred.
4. Observations: This a narrative of what was observed of the
client communicating in various settings, including types of
communication, whether the communication was successful,
4. Assessments, Evaluations, and eHelpers 95
how the client repaired communication breakdowns, and
so forth.
5. Interpretation of observations: These determine if the obser-
vations support the formal assessment results or support other
stakeholder observations.
6. Parent/caregiver interview: This interview discusses important
information related to client communication skills that support
(or don’t support) results.
7. Formal tests administered: It is helpful to begin this section
with a note that testing was completed via telepractice,
including the equipment used by clinician and client, as well
as the platform used. It would be helpful to include the upload
and download speeds of both clinician and client, particularly
if there were internet issues during the evaluation session. List
the tests and subtests administered and the test scores. In this
section, it is helpful to put this information in a table format. It
makes the scores easy to scan, compare, and contrast.
8. Interpretation of test results: It is important to discuss the
results of the formal tests, the informal measures, and deter-
mine if they support each other. In this section, there should
be a statement regarding whether the client would benefit from
services (therapy).
9. Summary and interpretation: Summarize the results in approx-
imately two paragraphs.
10. Recommendations and goals: Prepare a statement regarding
the need for therapy (if there is one) and recommend frequency
and duration, as well as the goals. Some school districts do not
want goals in the report, so be sure to check with the district to
determine if this is needed. Also, for third-party reimbursement
(insurance), be sure to check with individual providers for the
recommended format.
There are essentially two items that should be included in any
report where telepractice is used to assess a student. First, the fact
that the assessment was conducted via telepractice, along with a
96 Telepractice: A Clinical Guide for Speech-Language Pathologists
statement regarding the equipment used (both clinician and client)
and the videoconferencing platform. Secondly, it is imperative to
include any modifications made. These modifications could include
directions that were modified due to poor internet connectivity,
response format (such as using annotation tools in lieu of a point-
ing response, etc.), or using items from the home as substitutes for
items included in an in-person administration (e.g., items used in the
PLS-5). In addition, if the equipment used by the client was smaller
than a laptop or desktop (e.g., a tablet or a phone), it would also be
important to note this, as the size may have affected the client’s per-
ception of the picture items visually.
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5 Engaging Clients:
Case Scenarios
Introduction
Providing therapy via telepractice includes consideration of
evidence-based practice (EBP), client needs and goals, family
dynamics and other stakeholders. Once buy-in is established, the
SLP determines best practices and EBP for the client while taking
into consideration all these aspects. When goals are determined, then
SLPs can begin the process of finding materials that fit the individual
goals of each client.
Materials for teletherapy can take several forms: paper-based,
digital, websites, applications, SLP made materials, and so forth.
Adaptations may be necessary depending on the client’s skills and
abilities. Adaptions could include use of peripherals such as a docu-
ment camera or additional cameras, changing the contrast on mate-
rials (for a client with a visually-impairment), or headsets for client
and clinician for better auditory input and output. The SLP may also
use external microphones either on the client or clinician side to
enhance the clarity of the sound. Prior to beginning therapy, SLPs
should put thought into what might be adapted based on what is
known about the client. After working with a client for several ses-
sions, adaptions may need adjustments as rapport is established or
other situations arise that might affect the ability of the client to ade-
quately receive services.
101
102 Telepractice: A Clinical Guide for Speech-Language Pathologists
Other issues that arise during teletherapy could include cultural
and linguistic diversity, age of clients, willingness to participate in a
new service delivery model, emergency situations, among others. As
teletherapy evolves and changes, more is being researched and written
about how to make changes that benefit the client. In addition, it
requires a clinician to be creative and use their problem-solving skills
in order to provide best practices and EBP for the advancement of
their client’s skills.
This chapter presents case scenarios that showcase some of the
issues to be considered when providing teletherapy to various age
groups. These scenarios showcase the critical thinking process for
teletherapy, including areas of success and areas for improvement.
Case Scenario: Early Intervention
Background Information
Itak is 18-months-of-age and was referred to early intervention ser-
vices in his home state. He lives at home with his family that consists
of his mother and two older siblings (a sister, 3-years-of-age and a
brother, 7-years-of-age). Itak’s mother, Ms. H, works full-time as an
RN in a local hospital. She works a Monday through Friday shift, 9
am to 5 pm that does not allow her to take Itak to early intervention
services. Itak attends child care with his older sister from 8 am until
2 pm each day, when his grandmother picks him and his sister up
from child care and brings them home to meet Itak’s older brother
who walks home from school.
When Itak was 15-months-of-age, Ms. H, felt that he was not
developing at the same pace as his two older siblings and took him to
their pediatrician. The pediatrician determined there were potentially
motor and communication delays and referred him to IDEA Part C
services in his area. An arena evaluation was completed. Taking part
in the evaluation was an early intervention specialist, a physical ther-
apist (PT), an occupational therapist (OT), and a speech-language
pathologist (SLP). The results of the evaluation indicated that delays
5. Engaging Clients: Case Scenarios 103
were present, including late developing motor skills and limited
expressive language skills; although he did appear to be able to follow
directions at an age-appropriate level, his oral communications skills
were limited to approximately three words total. Itak frequently used
gestures to make some of his wants and needs known, often pointing
to what he wanted. Ms. H also noted that Itak was often frustrated
when he would attempt to verbalize and family members could not
understand what he needed. His 3-year-old sister was able to under-
stand his needs and verbalizations most often and acted as his inter-
preter, particularly in his child care setting. Itak readily imitated initial
sounds of words when prompted and did not appear to have apraxia.
Goals and Objectives
The goals of therapy included increasing his speech sound repertoire,
increasing vocabulary to include functional vocabulary for both home
and child care, and caregiver participation in therapy. All parties
agreed to these goals and were ready to move forward.
Parent coaching is considered best practice within a rou-
tines-based intervention for early intervention services. The objec-
tive is to improve child and caregiver participation within the natural
environment (ASHA, n.d.). Research (Cason et al., 2012; Olsen et al.,
2012; McDuffie et al., 2016) indicates that using a parent coaching
model is effective via teletherapy as it assists caregiver capacity-build-
ing and supports positive outcomes with the young client.
When working with clients in early intervention it is important
to work with families and other stakeholders (e.g., extended family,
child care providers, etc.) as it will facilitate improvement in commu-
nication skills for the young child. Using websites, apps (applications)
and other online resources should be done in a limited capacity. The
focus of therapy is on family routines.
Telepractice Applications
Because Itak’s mother works full-time, it is difficult for her to travel to
his child care site or home during the middle of the day. Although his
104 Telepractice: A Clinical Guide for Speech-Language Pathologists
grandmother was willing and able to participate in therapy sessions,
Ms. H was very interested in finding a solution for participating in the
therapy process. She inquired about finding an SLP who worked on
the weekends, but after some searching was unable to find someone.
Ms. H was eventually offered teletherapy, which she was a bit reluctant
to accept at first because she was not sure of the efficacy of teletherapy.
When the assigned therapist shared the research with Ms. H (exam-
ples: Olsen et al., 2012; McDuffie et al., 2016) she indicated she would
try it as long as she could log into the sessions in the afternoon when
she had a break during work. The SLP decided it would be best to do
twice-weekly sessions, one session in his home and one in his child
care setting in order to model language expansion for both the family
and child care provider.
The next step was to ensure that the setup at home was conducive
to teletherapy. The family had both an iPad and a laptop computer
that could both be used for therapy and also sent with Itak to child
care. The SLP initially had Itak sit in his high chair with grandmother
sitting next to him to assist with prompts. The SLP had grandmother
put toys in a large box or bag to keep out of Itak’s sight until she was
ready to introduce the toys. This worked for a very short time as Itak
protested after being in the high chair for about 5 minutes. It quickly
became clear that the SLP would need to change her approach to one
where Itak could move around more, and an approach that included
physical activity.
After a conversation with Ms. H and Itak’s grandmother, they
were able to set up teletherapy in a spare bedroom in their house with
a closed cabinet to store toys in. The family rotated various interesting
toys and activities in and out of the cabinet and Itak never knew which
ones would be available on a shelf within his reach. Grandmother and
Itak were able to move between the floor and table which assisted
with engaging him because he was able to move during the sessions
but still have a choice of activities as well as movement which was
incorporated in this session.
At his child care facility, the SLP was able to schedule the session
towards the end of his day there and grandmother would come early
in order to support the session at child care. It also gave the child
care provider the opportunity to observe sessions, participate when
5. Engaging Clients: Case Scenarios 105
the other children were napping, and carry over during Itak’s time
with her.
Ms. H was able to log into many sessions. She was typically
available at least once per week. This allowed her to participate in
therapy sessions as well as carry over any new skills during her time
with Itak at home. In addition, she felt she was part of the process and
was engaged in the therapy process that allowed her to be part of it.
Therapy and Materials
In early intervention, whether in person or via teletherapy, the focus
is on parent/caregiver coaching utilizing family routines. This enables
the clinician to use materials found in the home and demonstrate
to caregivers how to incorporate language skills into daily routines.
The family in this scenario worked with the assigned SLP to find a
mutually agreeable time in order for Ms. H to easily participate when
she could. This set up the ideal environment for providing family- and
community-centered therapy which is best practice for this age group.
Each week, the SLP worked with the mother, the grandmother,
and the caregiver to find daily routines and activities to work towards
Itak’s goals. Daily routines included mealtime, playtime, bath time,
and nap time routines. In addition, the SLP shared book-reading
activities on YouTube that assisted family members with modeling
this type of activity to improve language skills.
The family was happy to know how to expand speech sounds
and vocabulary skills during daily routines, which made it easier for
the family to carry over the skills they were learning that supported
Itak’s speech and language goals.
Challenges and Lessons Learned
Early intervention services can be challenging for a number of reasons
including, family buy-in, scheduling, finding appropriate activities,
and so forth. Obtaining buy-in from families for teletherapy, par-
ticularly for this age group (early intervention, 0 to 3 years) can be
106 Telepractice: A Clinical Guide for Speech-Language Pathologists
daunting as it is a relatively new service delivery model. However,
with proper planning, early contact with families to explain teleprac-
tice and demonstrate how it works can assist in getting over the hurdle
of acceptance. Sharing research in teletherapy with families is helpful
as well.
In advance of the first teletherapy session, setting up a conver-
sation with the family to not only explain this service delivery model,
but also to determine typical family routines and find out materials
available in the home goes a long way to ensure successful sessions.
Discussing speech and language goals with the family ensures buy-in
for therapy sessions. Continuing these discussions on a regular basis to
obtain feedback from families on their perceptions of therapy sessions
will assist in continually improving the therapy process. Planning for
sessions ahead of time will also support families to prepare for each
session and have materials ready. It keeps the lines of communication
open, which is important to the success of early intervention services,
whether in-person or via telepractice.
Case Scenario: Preschool Telepractice
Background Information
Eduardo is a 4-year, 6-month-old male student attending part-time
preschool three times per week. For the past year, Eduardo has been
seeing a speech-language pathologist for speech-language services via
telepractice. Eduardo’s telepractice sessions are provided in his home
by a remote SLP, Saundra. Sessions are 30 minutes two times per week,
focusing on expressive and receptive language, and social language.
Eduardo lives in a busy household. He lives at home with his
mother, father, grandmother, and 7-year-old sister. English is the
primary language of the home, but Spanish is also spoken. Accord-
ing to the parent report, Eduardo likes to play with cars, organize
them by color, and then line them up. Eduardo likes to play with his
tablet and his mother’s phone. Eduardo also loves to be outside and
explore new playgrounds and parks. His mother reports that she has
5. Engaging Clients: Case Scenarios 107
not observed him engaging in pretend/spontaneous or imaginative
play. She also reports that Eduardo is sensitive to loud sounds. If the
smoke detector goes off when they are cooking, he will become upset
and leave the room. Eduardo is described as a picky/restrictive eater.
His mother reports that he refuses to eat almost all foods; his diet
consists of liquids and vitamins. Eduardo does enjoy songs, can recite
the alphabet, and can count to 10. When Eduardo wants something, he
will lead his parents by hand to indicate his wants, needs, and interests.
Saundra has seen Eduardo for speech-language sessions for the
past few months for sessions via telepractice. His attendance has been
consistent, but his participation has been sporadic. Eduardo is an
active child, often leaving the room during sessions or darting in and
out of Saundra’s view using a fixed, internal video camera installed
on the family laptop. Saundra is struggling with engaging Eduardo in
online sessions. She finds that the 30-minute sessions may be too long
or that her activities are not engaging. She is searching for ways to
increase student and parent participation. To facilitate parent training
and participation, Saundra starts with reviewing her initial assess-
ment and therapy notes. She realizes it has been over a year since she
initially collected background information and completed a parent
interview. Saundra decides it is long overdue to interview the parents
about Eduardo’s interests as they may have changed. She also hopes
to use this information to spark parent training and participation.
Saundra puts together a plan to observe Eduardo playing in a
naturalistic setting in the home with the parent and sibling present via
telepractice. During this observation, Saundra has several goals. First,
she wants to create a situation where Eduardo is comfortable and
observes the types of toys, books, and manipulatives he enjoys. She
also wants to determine the types of toys and activities that Eduardo
is naturally drawn to and how Eduardo, the parent, and the sibling
interact with one another.
Telepractice Applications
After observing Eduardo for approximately 30 minutes, Saundra lets
the parent know that Eduardo can be excused and turns her attention
108 Telepractice: A Clinical Guide for Speech-Language Pathologists
to parent coaching. Saundra would like to see increased parent partic-
ipation in parent coaching and participation and hopes to use parent
coaching to achieve this goal. Saundra has mentioned this goal to
the parent at the end of teletherapy sessions to reiterate the impor-
tance of parent involvement in a successful preschool telepractice
therapy model. Saundra points out that although Eduardo receives
speech-language services via telepractice twice a week and attends
preschool three times a week, he spends most of their day at home
with his parents, reiterating their importance in his treatment plan.
Saundra then leads the parent in a guided language stimulation
activity with Eduardo. Saundra leads the activity by using a watch-
lead-speak approach:
1. She asks the parent to observe how the SLP leads Eduardo in
the language stimulation activity.
2. The parent leads Eduardo in the same activity.
3. Saundra and the parent discuss how the activity went and ways
to increase language stimulation the next time.
Saundra and the parents repeat this cycle for approximately
15 minutes, observing one another interacting with Eduardo and
stimulating his language and social skills. Saundra makes sure to
explain the therapeutic goals, objectives, and targets of the session as
they go along. At the end, Saundra concluded by giving the parent a
few minutes to ask questions and discuss the combined session. Since
the session was completed via telepractice, Saundra makes sure to ask
the parent if they would like to view a recording of the session (given
prior permission) for review at a later time. In conclusion, the SLP
outlines that the parent is welcome to attend and trial new strategies
as needed in the subsequent sessions.
Critical Thinking Questions
1. Saundra waited a year to complete a new parent interview and
discuss the need for increased parent interaction and training.
5. Engaging Clients: Case Scenarios 109
Was this an appropriate amount of time when working remotely
via telepractice? Why or why not?
2. Saundra wanted to evaluate and improve Eduardo’s participation
and engagement in telepractice sessions. What are successful
and engaging activities you have used with preschool clients?
3. Saundra’s goals primarily focused on parent training and
coaching. She did not involve the preschool teacher or setting.
How would you recommend adding the preschool teacher or
staff when improving preschool services and parent involve-
ment via telepractice?
Case Scenario: Culturally and
Linguistically Diverse Clients
Background Information
Every cultural model finds its own answers to internal impulses
that occur over time, but above all to those produced by encounters
with other cultures or cultural phenomena. This is a case in point
for changes arising from the introduction of advanced technologies,
especially during the COVID-19 pandemic when many services, from
education to business to healthcare and allied health, transitioned
online. The introduction of new technologies in speech-language
pathology, for example, has led to changes that required readjust-
ment, or new articulations, of relations between the various fields of
knowledge and the daily life of both the individual and the commu-
nity. Some cultures view illness and disability as manifestations of the
spirit or a consequence of generational mistakes or wrongdoing. The
Americans with Disabilities Act of 1990 (ADA) is a civil rights act that
prohibits discrimination against individuals with disabilities (ADA,
n.d.). Although, it is essential to acknowledge that although a family
may identify with or be from a particular geographical area or race/
ethnicity, not all families adopt the same cultural beliefs or practices
of those locations or traditions.
110 Telepractice: A Clinical Guide for Speech-Language Pathologists
Telepractice Applications
Kofi is a 7-year-old, second-grade student attending an English-
speaking elementary school. Kofi’s family are refugees from Ghana and
live in a primarily English-speaking community where there are few
other refugee families. Kofi speaks English and Akan and has been
exposed to English since birth. Kofi was referred to his school speech-
language pathologist by his mother because Kofi has been repeating
words often and is difficult to understand because of this. The SLP
scheduled an evaluation planning meeting via telepractice videocon-
ference and invited Kofi’s parents, both Ghanaian refugees. The SLP
called in the district interpreter/cultural liaison if there were any ideas
or concepts that may be difficult to explain in English and informed
the parents ahead of time of their presence in the teleconference.
Kofi’s parents had difficulty logging into the videoconference.
The SLP was puzzled by this since she had held successful videocon-
ference meetings with most parents. She followed her usual proce-
dures including sending an email explaining the meeting, sending a
calendar invitation, and even sending a reminder (all in English). The
SLP even sent a reminder text, although she did not receive a response
from the parent. After approximately 10 minutes of waiting, the SLP
contacted the family by phone and with the help of the interpreter,
the parents successfully logged into the videoconference with the SLP.
Once online, the parents described how this was the first meeting they
have had online concerning their child and it was not the preferred
method of communication. They did agree to attend in this fashion
considering the SLP was remote.
After completing the introductions, the SLP explained the goal
of the meeting to discuss the possibility of Kofi’s “disability.” Via
videoc onference, the SLP noticed that Kofi’s father had many ques-
tions about the use of “disability.” He wanted more clarification about
Kofi’s speech and did not understand why the term disability was
being used. Kofi’s mother also expressed concern about the language
used during the meeting and asked that the SLP solely explain what
was going on with Kofi’s speech and why he repeated sounds. In their
culture, the term “disability” is used to describe mental or cognitive
impairments, and they did not want it used to describe their son.
5. Engaging Clients: Case Scenarios 111
The SLP used the remaining time to describe stuttering using some
English-based materials she had gathered and no longer used the term
“disability” during the meeting.
Critical Thinking Questions
1. In your opinion, what did the SLP do correctly when setting
up the meeting via telepractice? Identify 2 to 3 specific actions
or steps.
2. Before meeting with the family, what could the SLP have done
to learn about the Ghanaian culture?
3. The family expressed dislike/disapproval of the term “disability.”
What could the SLP have done to explain the terminology better?
Case Scenario: Elementary
Background Information
When working online and remotely via telepractice, as with any
communication therapy and intervention aspect, the clinical decision-
making process is made by the professional, and here the speech-
language pathologist. When planning therapy, digital materials that
address many different treatment approaches should be considered.
From the normative approach, the bottom-up discrete skill approach,
and even specific approaches, including Hodson’s cycles approach
(Hodson & Paden, 1991), could be considered. The SLP must analyze
their digital materials for variety and best-practice as one would in
the in-person setting.
Telepractice Applications
Justine is an SLP that has recently transitioned to telepractice.
Although Justine has been an SLP for over 10 years, she has primarily
112 Telepractice: A Clinical Guide for Speech-Language Pathologists
practiced in the in-person setting in elementary schools. Now, she
is embarking on a new experience working online and remotely via
telepractice in a K–12 online-only elementary school. Following
ASHA and state licensure guidelines, she will be seeing students in
a state other than the state she resides in and is excited about the
new possibilities.
Justine is reviewing her new caseload. She will be the primary
SLP for an online school serving ages 5 to 10. She will be seeing stu-
dents in groups of two to three. As she reviews the paperwork for
each student, she notices that a large part of her caseload consists of
articulation, phonology, and speech sound disorders. The students
in the group have mild to severe articulation and phonology goals
and objectives. Each student in the group has goals and objectives for
vocalic and non-vocalic /r/, /s/, and voiced and voiceless /th/. Each
session is 30 minutes in duration.
As Justine is preparing for her new caseload via telepractice, she
is particularly concerned about setup. She is used to having a small
but private speech room, and working via telepractice is a significant
change. Justine spends a significant amount of time setting up her
own environment, investing in a new monitor, standing desk, and
lighting. However, Justine is particularly concerned about the setup
of the telepractice setting for each of her students. Each student will
be in their own home, with the school being online/virtual and not
a brick-and-mortar school. Justine wonders how to describe the best
environment for their sessions to the parents and students. Justine
worries that some students may not have headsets/earbuds, whereas
others may have them but prefer not to wear them. Justine decides to
create a parent-friendly checklist of items required for therapy. The
checklist includes icons on how to prepare for therapy that include
the headset and recommendations for lighting, distractions, and
parent involvement.
Following the setup, Justine turns her attention to materials and
lesson planning. Considering that much of her caseload is diagnosed
with articulation and speech sound disorders, Justine wonders how
to integrate materials that best address articulation goals for groups
of students. Justine begins by carefully reviewing each student’s goals
5. Engaging Clients: Case Scenarios 113
and objectives and previous progress reports. She then creates a folder
for each group, carefully curating digital materials for articulation
and speech sound patterns with activities that may work best in the
group setting.
Critical Thinking Questions
1. What are the most critical areas to establish both physically and
virtually when establishing a new teletherapy setting?
2. Justine had over 10 years of in-person experience before
taking a position providing telepractice sessions. Is having an
in-person experience an advantage? Why or why not?
3. Is it necessary for all students to have access to headsets
for teletherapy sessions? Why or why not? How would you
encourage school administrators and students to support your
recommendations?
K–12 Case Scenario: Language Intervention
Background Information
Students diagnosed with specific language impairment (SLI) are a
part of the caseload of many SLPs treating school-age and elementary
students. Most typical of individuals diagnosed with SLI is the diffi-
culty in learning and consistently using the grammatical morphemes
of their language, although disruptions in the learning and use of
other language areas both receptive and expressively are frequently
observed (Bedore & Leonard, 1998). Specific language impairment
is a disorder that may underlie both the learning of oral language
comprehension and production and written language comprehen-
sion and production (e.g., reading, writing). With the connections
between oral and literate language learning, the SLP must also be
well-versed in the foundations of typical development in both of these
communication modes.
114 Telepractice: A Clinical Guide for Speech-Language Pathologists
Telepractice Applications
Lisa is an experienced SLP in both the in-person and telepractice set-
tings. She has a small private practice and sees students both in-person
and via telepractice. Lisa is taking a new student via telepractice diag-
nosed with specific language impairment (SLI). His name is Luke.
Luke is a 10-year, 5-month-old student enrolled in the fourth
grade at a brick-and-mortar elementary school. He has previously
been diagnosed with receptive and expressive language delay. During
a parent interview, the parents noted that Luke began receiving speech
and language therapy at 24-months-of-age. Although he has made
some progress, they were certain that Luke continued to remain
behind his classmates in his language competencies since kindergar-
ten. The parents had particular concerns that over the last several
years, Luke has demonstrated some difficulty reading and with lit-
eracy, and were concerned about this escalating as he enters later
elementary years and into middle school.
The parents expressed some hesitancy and excitement about
teletherapy. They are advocates for their child and want to see prog-
ress, and also appreciate the flexibility teletherapy sessions offer
considering their busy schedules. A teletherapy schedule was set up,
following the IEP recommendations, including sessions two times per
week for 30 minutes.
Based on her clinical expertise the SLP, Lisa, considers several
options. She decides after reviewing her goals and objectives, that
teletherapy approaches combining Luke’s developmental, functional,
and classroom curriculum should be considered. She considers that
continuity between Luke’s language comprehension and production
would be helpful to his successful literacy learning. Lisa considers that
she and the classroom teacher would need to be in communication to
best plan and implement a program that would enhance the carryover
of language-learning strategies. She also wanted to consider multiple
modalities to maximize Luke’s learning and retention. Finally, con-
sidering the telepractice setting, Lisa surmised that the inclusion of
digital materials, activities, and reinforcement would be a positive
aspect to support these approaches. Lisa could use materials also used
in the classroom during the telepractice sessions and scheduled a time
5. Engaging Clients: Case Scenarios 115
to consult with the teacher on book series and materials currently in
rotation in the classroom.
After three sessions, Lisa consults with Luke’s classroom teacher
via email. The classroom teacher reports that Luke is attending ses-
sions with increased excitement. He appears to be gaining confidence
in his ability to complete the writing tasks in the classroom. He is also
engaging in group activities in the classroom and collaborating with
other students in reading and writing tasks.
Critical Thinking Questions
1. Do you agree with the treatment approach for this student?
Why or why not?
2. What are ways the SLP could explain her treatment approach to
parents who may be experienced with speech-language services
but not with telepractice services?
3. The SLP consulted with the classroom teacher in planning and
progress reporting. How would you integrate parent involve-
ment in this scenario?
Case Scenario: Middle School
Background Information
JR is 13-years-old and in seventh grade at his middle school. He has
received speech and language therapy since preschool. Initially, he
presented with a phonological disorder that was addressed during
preschool and kindergarten. When JR entered first grade, it was noted
that he was having difficulty accessing the curriculum. Subsequently,
he was diagnosed with a language learning disorder that has been
addressed since third grade. As JR entered middle school, he was
being seen two times per week for 30 minutes per session. His school-
based SLP noted that he had become resistant to being pulled out for
116 Telepractice: A Clinical Guide for Speech-Language Pathologists
language therapy as no one in his friend group had these services
and he didn’t like being pulled out of class. He often refused to attend
therapy and his IEP team noted that since he had begun refusing
services, his grades had dropped in some of his classes.
After a meeting with the IEP team that included his parents and
JR, it was determined that a new evaluation was warranted to explore
whether or not he could benefit from a different level of services and
to determine if there were other areas of need that were not being
addressed. Results indicated that JR had made some progress since his
last assessment (2 years prior), he was showing plateaus in his reading
comprehension as well as in language skills. The school psychologist
also reported some signs of depression and referred him to the social
worker working in the on-site health clinic at the school. The psychol-
ogist felt that some of the refusal for speech-language therapy and lack
of progress in the classroom was due to JR’s depression.
In the meantime, the school SLP was leaving the district at the
end of the first semester of school due to her spouse who was in the
military and being transferred to a new base out-of-state. The Special
Education Director knew of this in advance and had arranged for a
tele-SLP to provide services to JR. JR was introduced to the new SLP
during his last few sessions of the semester. At the end of the semester,
JR informed his parents that he would be receiving speech-language
services on the computer. His parents were very upset that an SLP
would no longer be providing services and JR would be placed on
the computer instead. JR’s parents tried to call the Special Education
Director but she had left for winter break, so they left a message. As
one might imagine, the parents were quite upset about this change
and concerned about their son’s speech and language services being
discontinued, to be replaced by a computer. This did not meet what
had been put in JR’s I.E.P. and it had not been discussed with them.
When school started again in January, JR, after listening to
how upset his parents were, did not want to attend SLP services on
the computer and refused services. The tele-SLP was a bit confused
because she felt she had made a connection with JR as they had dis-
cussed incorporating some of his favorite subjects/topics into therapy
sessions. The tele-SLP immediately contacted JR’s parents to help her
figure out why JR was continuing to refuse therapy and it became
5. Engaging Clients: Case Scenarios 117
clear that there had been a miscommunication with the family. The
tele-SLP was then able to clear up the misunderstanding as well as
invite the parents to observe a session.
Goals and Objectives
Because of his diagnosis of Language Learning Disability, JR’s overall
goals included working on expressive language skills, both verbal
and written. More specifically, his most difficult subjects were in
History and Science primarily due to lack of comprehension of vocab-
ulary. The goals his SLP developed included work on morphology
to learn root words, prefixes, suffixes and to give him strategies to
decipher word-meanings on his own. JR also needed to improve his
written skills by learning organizational skills for writing reports and
responding to comprehension questions and increasing his use of
more complex sentence structure.
Telepractice Applications
The types of skills that JR was working on with his on-site SLP easily
carried over to a telepractice setting. However, JR had become reluc-
tant to attend therapy. He noted that it was boring and he didn’t see
how it was helping his grades. When the tele-SLP met with JR toward
the end of the first semester, she talked with him about his likes and
dislikes, and asked him about subjects that were difficult and why he
found them difficult. This led her to understanding more about who
JR was and assisted with planning his therapy in order to reengage
him in the process.
When she met with JR after winter break, she found he was still
reluctant even though he had been excited prior to the break about
the way that the tele-SLP had presented what her therapy sessions
would look like. After a discussion with him about his changed atti-
tude, the tele-SLP discovered that JR’s parents were not in support
of teletherapy and they didn’t want him to participate. The tele-SLP
immediately called his parents to help allay their fears. After a long
118 Telepractice: A Clinical Guide for Speech-Language Pathologists
discussion with them, she discovered that school personnel had not
explained teletherapy to them and they were under the impression
that JR was going to be sitting in front of a computer program for his
speech-language therapy. The tele-SLP invited JR’s parents to attend
a session remotely so they could observe JR’s therapy session. This
helped allay their fears and the SLP saw a change in his attitude and
found that JR was excited now about attending therapy because he
was seeing how therapy related directly to his school work.
Therapy and Materials
At the middle school level, it is important to strive for a balance
between using curriculum-based material and online activities that
keep an adolescent engaged. There are many apps (applications)
available as well as websites that incorporate interactive activities
appealing to middle school aged students. It is important to review
them before using them as some are purely games and are difficult to
incorporate therapy goals. However, there are some that easily allow
the SLP to incorporate curriculum-based materials that will keep
these students engaged. In this scenario, when the tele-SLP shared the
types of activities she used and showed JR what she had planned, he
was excited and absorbed into the activities. These activities did not
feel like typical therapy activities and felt new, different, and exciting.
Materials at this age level should include curriculum-based
vocabulary so the client recognizes that the activities relate directly
to the classroom and will carry over easier due to familiarity with
the vocabulary. It is important to ensure that clients see the value of
the SLP’s services and that it directly relates to their daily lives and
activities. Using curriculum-based materials facilitate learning and
engage students more effectively.
Challenges and Lessons Learned
One of the challenges in this scenario was communication with the
family. It became clear that the parents of this student had not been
fully informed about teletherapy. This was more common than it
5. Engaging Clients: Case Scenarios 119
should be prior to the pandemic when many more families and stake-
holders were introduced to teletherapy. Often, a brief explanation of
teletherapy was given to families and stakeholders in writing with
no opportunity to ask questions or to see what teletherapy actually
entailed. Communication with all stakeholders (parents, administra-
tors, principals, teachers, community, etc.) is critical to the success of a
teletherapy program. Everyone needs to be on board and in agreement
that teletherapy is a good option for clients. When the communication
is limited and there is no opportunity to ask questions, then stake-
holders may become skeptical and think that telepractice is something
that it isn’t. Although much of the communication happens at an
administrative level, sometimes the families and other stakeholders
get lost in the communication loop. Good communication makes for
an effective and efficient start-up of telepractice services.
Case Scenario: High School
Background Information
Jayda is a 10th grader at a high school in Modoc County in the far
northeastern corner of California. It is a remote area with few SLPs in
the entire county. However, Jayda has been fortunate because during
her school years, Sandra, her SLP, has developed knowledge and skills
in the use of AAC (augmentative and alternative communication)
over the years. When Sandra first started working with Jayda in kin-
dergarten, she had limited knowledge of working with clients who
were AAC users. However, the school district she worked for was able
to provide her with continuing education courses and training that
increased her knowledge and skills in this area and Sandra became the
AAC expert for the county. She was also able to share her skills with
other school districts in nearby counties and support other students
who were AAC users.
In the summer before Jayda entered 10th grade, Sandra retired
from the schools after many years in the district and moved to the
desert in southern California. Sandra was concerned as there were
no other SLPs in the area who had her expertise in AAC. The district
120 Telepractice: A Clinical Guide for Speech-Language Pathologists
assured Sandra that they would find someone who could serve all her
students. As the school year began, the district was unable to find any
SLP to fill the position, let alone someone with Sandra’s expertise in
AAC. The district approached Sandra to see if she would be willing
to continue providing services to her AAC students, temporarily, in
the district via telepractice. If she was, the district would continue to
search for an SLP to fill her position and then have Sandra train the
new SLP. Sandra agreed to this but asked for time to learn more about
telepractice. Sandra spent the next week researching telepractice and
what she would need in order to serve her clients using telepractice.
As Sandra researched telepractice, she found enough information
to assure her that it could be an appropriate service delivery model for
her students (Anderson et al., 2012; Douglas et al., 2021; Fissell et al.,
2015). She made a list for the district of what was needed on their
end (computer, high-speed internet, cameras, microphones, etc.) and
requested that they set up the computer in the speech office on site
at the high school. Sandra also had the school IT department check
to ensure the internet speeds and bandwidth would be sufficient for
teletherapy during the hours she would be seeing her students. Lastly,
Sandra contacted all the families individually to discuss the teleprac-
tice option with them. In addition, she held a videoconference call for
all the families to show them how teletherapy works to ensure that
she would be there live with her clients. Most families were on board,
with a few reluctant at least initially. However, by inviting families
to teletherapy sessions, she was able to win over these families. In
addition, Sandra had the respect of these parents as they had worked
with their children for so many years. The respect she had developed
over the years had helped them to make the transition to telether-
apy without much convincing after the initial reluctance with a new
service delivery model.
Sandra dove into therapy with relish as she was finding she
enjoyed teletherapy. During her first session with Jayda, Sandra
realized that there were some aspects of teletherapy that she had
not thought about that were affecting Jayda’s responses in telether-
apy. She did not think about how Jayda would access the computer,
or, how she (Sandra) would be able to see how Jayda accessed her
device. This was critical for working with students who are AAC users
5. Engaging Clients: Case Scenarios 121
as Sandra needed to ensure that Jayda’s device remained accessible
and was organized for ease of access. Sandra had not thought about
programming Jayda’s device remotely but was able to train one of
her teachers and her parents. However, Sandra found that there was
not much communication between the parent and teacher to deter-
mine who was responsible for programming Jayda’s device. Sandra
realized there was a miscommunication here and once it was deter-
mined who would program the device for different classes, services
went more smoothly.
Goals and Objectives
Jayda’s goals included expanding her vocabulary and language skills
and expanding and increasing her use of her AAC device outside of
the classroom. Jayda has been using some form of AAC since early
in elementary school. Her current device is relatively new as she had
outgrown her previous one. Jayda was not yet comfortable accessing
the device when she was with peers or out in the community. She
used it fairly consistently in the classroom as her teachers noted that
she was making progress in the curriculum, showing improvement
in her grades, increased knowledge of the curriculum and frequently
participating in classroom discussions.
Telepractice Applications
Telepractice is useful in many different types of settings and with
a wide variety of clients as long as it is set up appropriately for the
clients and there is good communication with the stakeholders. In
the case of Jayda, her SLP did her homework with reviewing the
research but did not look at specifics for teletherapy with AAC users
and also realized some communication was lacking with Jayda’s team.
However, Sandra was able to recover by repairing the issues that came
up which she handled well.
When working with a client who uses AAC, it is critical to
remember that there are additional steps that need to be taken into
122 Telepractice: A Clinical Guide for Speech-Language Pathologists
consideration when setting up teletherapy. Once the basics are con-
sidered, the tele-SLP needs to consider whether or not additional
technology is necessary such as an additional camera to observe
clients accessing their devices, who will program the device, who
will coordinate communication between team members and, impor-
tantly, ensuring all stakeholders including families are informed early
on that their family member will be receiving teletherapy services.
Having the opportunity to observe a session, and have their questions
answered and fears allayed goes a long way in obtaining buy-in from
all stakeholders.
Therapy Materials
Hall et al. (2020) offer a form for planning for teletherapy sessions.
It is helpful to use a form like this or a similar document to assist in
planning for each session. Planning for sessions should start with
looking at client goals, then looking at EBP, and finally choosing
materials that fit. Choosing materials should not be the first thing an
SLP does. It should be the last to ensure that materials meet the needs
and goals for each client.
There are numerous tools available to use on the internet, in
online stores for therapy materials as well as applications. However, at
the high school level, materials should be curriculum-based as this will
help with the client understanding the relevancy of therapy services.
There are tools available to turn curriculum material into interesting,
interactive activities for high school age clients. These include Power-
Point™, Google Suite (Docs™, Slides™, Earth™, etc.) and tools such as
Boom Cards and LessonPix, which allow the clinician to develop their
own materials that are engaging and relevant to each client.
Challenges and Lessons Learned
When clients have additional needs beyond a speech and language
delay, such as AAC users, tele-SLPs should take these needs into con-
sideration and think about how these needs may change how therapy
5. Engaging Clients: Case Scenarios 123
is presented. This should be completed in the initial phase of telether-
apy implementation as it will impact whether or not a client has the
ability access a computer, the need for an eHelper, and what additional
peripherals will be necessary to provide services that are equivalent
to in-person services. These are just some of the challenges tele-SLPs
face when working with clients who are AAC users.
This scenario also showcased the need for ensuring all stake-
holders are included in the discussion for teletherapy. With all stake-
holders (client, family, school personnel, other professionals, etc.) on
board, the transition to teletherapy is easier and with less bumps in
the road. Buy-in supports the success of any teletherapy program.
Case Scenario: Adult
Background Information
Elena is a 64-year-old female who had a left CVA 3 months ago. The
CVA left her with dysphagia and moderate aphasia that left her with
limited language comprehension and production skills. Elena was
evaluated in the hospital for dysphagia and treated during her 8-day
stay. Upon discharge from the hospital, Elena was sent to a skilled
nursing facility to continue her rehabilitation.
Before her stroke, Elena had been a successful manager at her
technology company. She ran the human resources (HR) department
and was well-liked by her peers. Elena had an active social life, trav-
eling with her husband and children, entertaining friends and family,
enjoying the theatre, and other social activities. She was also physi-
cally active, walking daily with her husband or friends. She enjoyed
an occasional hike and bicycle riding in good weather.
Elena was discharged to her home when the dysphagia had
resolved, and she was safe to eat and drink without assistance or
reminders. However, she continued to need speech and language
therapy to continue to improve her communication skills. Lou, an
SLP, was assigned to see Elena in her home to continue her rehabilita-
tion. Because Lou was located out of state (but was licensed in Elena’s
124 Telepractice: A Clinical Guide for Speech-Language Pathologists
home state), the family agreed to telepractice services. Elena’s family
was hesitant to participate in telepractice services but decided to give
it a try. It would have been at least two months before one of the local
SLPs was available to see her in person, in her home.
Elena was frustrated by her inability to communicate at the level
she had prior to her stroke, which was causing her to withdraw from
family and friends. In addition, Elena was advised not to drive or ride
her bicycle until her physician, and physical therapist, cleared her.
Goals and Objectives
Lou decided to conduct an informal evaluation to determine current
language comprehension and production skills. It had been almost
seven weeks since the last evaluation, and it was apparent, after Lou’s
first session with Elena, that she had made some progress. Once he
completed his informal assessment, Lou noted that Elena’s auditory
comprehension was mildly impaired and oral expression was mod-
erately impaired. Problem-solving skills were in the mild-moderate
range. Having this information, Lou set Elena’s goals to improve her
skills in these areas. After consulting with the family, everyone agreed
to the goals. Elena, in particular, was ready to take on the challenges
of therapy as she wanted to get better and get back to her pre-stroke
skills. She had enjoyed her job and received much satisfaction from
it and, she wanted to get back to work and her very active social life.
Telepractice Applications
Before their first teletherapy session, Lou had spoken to Elena and her
husband on the phone. They both indicated they were familiar with
Zoom, which Lou was using for their teletherapy sessions. During this
call, Lou collected information from the family about Elena’s func-
tioning before the stroke, with Elena’s husband providing most of the
information. Lou also did some research to determine best practices
for working with clients with similar profiles via telepractice. In a
5. Engaging Clients: Case Scenarios 125
recent systematic review of telepractice services for adults, Weidner
and Lowman (2020) found in a review of thirty-one relevant studies
identified that the results supported telepractice as a service delivery
model for adults. Several other articles endorsed telepractice services
for adults, including Hall et al. (2013) and Cherney et al. (2011).
When Lou logged on to their first session, Elena did not log
in, and he was a bit confused as to why. He had sent the email with
the link to his Zoom room. Elena and her husband agreed to the
date and time of the session. After 5 minutes, Lou decided to call
Elena. She answered her phone and told Lou she was having trouble
logging on. Lou started to walk her through the process of logging
on but realized that her limitations in comprehension were making it
challenging to convey to her what she needed to do. He asked to talk
with Elena’s husband, and Elena hung up the phone. Lou assumed
this was an accident and proceeded to call her husband on his cell
phone number. Elena’s husband was at work, so he could not assist
Elena with logging on even though they had all assumed that Elena
would be able to do this. Lou realized his mistaken assumption after a
conversation with Elena’s husband and decided to rectify the situation
by providing a step-by-step guide that included written instructions
along with a visual guide. For the next session, Lou ensured that her
husband supported Elena as she worked through the instructions.
Once Lou and Elena’s husband were satisfied that Elena could do this
on her own, he was able to safely go back to work and leave Elena to
log in on her own at the appointed time.
Therapy Materials
Lou decided to use books to engage Elena in therapy. He knew that she
was well-educated based on the history he had collected from her and
her husband before the start of treatment. Lou’s work with individuals
with aphasia for the past 10 years informed his work providing ser-
vices via telepractice. He assumed that he could adapt what he knew
as best practices would work via teletherapy with some adaptations.
Lou chose a book he thought Elena would enjoy and found an online
126 Telepractice: A Clinical Guide for Speech-Language Pathologists
version with several reading levels to facilitate comprehension. Lou
started with the lower reading level because it met his client’s skills.
As Lou introduced the book to Elena, she was relatively quiet and not
very responsive during therapy.
With some probing, Lou discovered that Elena was not inter-
ested in reading books at the moment. Lou initially thought that it was
due to her awareness of her decreased communication skills. When
he was able to discuss with her, Elena felt the most important thing to
work on was conversation with her friends about what was important
to her and to share her life with friends and family. Lou realized that
he had made a mistake in not encouraging Elena to speak up during
the initial interview as he had allowed Elena’s husband to do most
of the talking. Although her husband knew Elena’s challenges very
well, he looked at her from his perspective and what was important
to him. Once Lou realized this, he was able to find materials more
suited to Elena’s needs. He asked for photos of her family and friends
and used those to establish a vocabulary that was significant for her
and relevant. This increased Elena’s participation in therapy, and she
readily began to communicate with her husband about what she had
learned in treatment. In addition, Elena wanted to start to see friends
again and return to her social life. Lou could incorporate these goals
into therapy which allowed Elena to continue to improve her com-
munication skills.
About two months into therapy, Elena logged on and said she
wasn’t feeling well. Lou noted that she was processing information
more slowly than in the past couple of weeks, which caused him
concern. She said she was feeling lightheaded. Lou momentarily
panicked as he knew he couldn’t call emergency services via the 911
system because he was out of state. He kept Elena on the videocon-
ferencing platform while he called her husband, who happened to
be on his way home for lunch with Elena. He arrived within minutes
and decided to take Elena to the hospital out of an abundance of
caution. This incident unnerved Lou because he was concerned about
Elena’s well-being. It turned out that Elena was a bit dehydrated, and
with some fluids, she was fine. However, Lou learned a lesson about
obtaining emergency phone numbers beyond the spouse or other
family members.
5. Engaging Clients: Case Scenarios 127
Challenges and Lessons Learned
There are two primary lessons in this scenario. First, and most impor-
tantly, when working with any clients, not just adults, SLPs should
obtain the direct-dial phone numbers to fire, police, and ambulance.
When the SLP is not in the same state or even if they are in the same
state but not the same city or locality, dialing 911 will not call the
client’s local emergency services. It is critical to obtain direct-dial
phone numbers for local emergency services if family members are
not present if these services are required. If the client is in another
setting other than home, it is essential to obtain emergency procedures
for that site (e.g., school, clinic, hospital, etc.) and who to contact in
case of an emergency.
The second lesson from this scenario is to ensure that the client’s
voice is heard, whether it is an adult or child. Although it may be dif-
ficult, especially because SLPs are working with people with commu-
nication disorders, collecting information from families is essential.
Still, it is equally important to ask the client themselves to participate
in these conversations, so that they are asked for input, even if it is
a simple as yes/no responses about likes and dislikes. Setting up a
positive interaction between client and clinician goes a long way in
establishing rapport, which facilitates client progress.
References
Americans with Disabilities Act (ADA). (n.d.). https://www.ada.gov/
Anderson, K., Boisvert, M. K., Doneski-Nicol, J., Gutmann, M. L.,
Hall, N. C., & Morelock, C. (2012). Tele-AAC resolution. Inter-
national Journal of Telerehabilitation, 4(2), 79–82.
American Speech-Language-Hearing Association (ASHA). (n.d.).
Practice portal on early intervention. https://www.asha.org/prac
tice-portal/professional-issues/early-intervention/#collapse_3
Bedore, L. M., & Leonard, L. B. (1998). Specific language impairment
and grammatical morphology: A discriminant function analysis.
Journal of Speech-Language-Hearing Research, 41(5), 1185–1192.
128 Telepractice: A Clinical Guide for Speech-Language Pathologists
Cason, J., Behl, D., & Ringwalt, S. (2012). Overview of states’ use of
telehealth for the delivery of early intervention (IDEA Part C)
services. International Journal of Telerehabilitation, 4(2), 39.
Cherney, L .R., Kaye, R. C., & Hitch, R. S. (2011). The best of both
worlds: Combining synchronous and asynchronous telepractice
in the treatment of aphasia. Perspectives of the ASHA Special Inter-
est Groups, 21(3), 83–93. https://doi.org/10.1044/nnsld21.3.83
Cohn, E. R. (2012). Tele-AAC resolution. International Journal of
Telerehabilitation, 4(2), 79.
Douglas, S. N., Biggs, E. E., Meadan, H., & Bagawan, A. (2021). The
effects of telepractice to support family members in modeling
a speech-generating device in the home. American Journal of
Speech-Language Pathology, 30, 1157–1169.
Fissel, S., Mitchell, P. R., & Alvares, R. L. (2015). An adpated assess-
ment model for emergent literacy conducted via telepractice. SIG
18 Perspectives on Telepractice, 5, 48–56
Hall, N., Boisvert, M., & Steele, R. (2013). Telepractice in the assess-
ment and treatment of individuals with aphasia: A systematic
review. International Journal of Telerehabilitation, 5(1), 27–35.
https://doi.org/10.5195/ijt.2013.6119
Hall, N., Juengling-Sudkamp, J., Gutmann, M. L., & Cohn, E. R.
(2020). Tele-AAC, augmentative and alternative communication
through telepractice (pp. 57–80). Plural Publishing.
Hodson B., & Paden E. (1991). Targeting intelligible speech: A phono
logical approach to remediation (2nd ed.). Pro-Ed/College Hill.
La Trobe University Center for Research Excellence (CRE). (n.d.).
Resources for health professionals. https://cloudstor.aarnet.edu.au/
plus/s/gQw3XLSKiY4Kg9g
McDuffie, A., Oakes, A., Machalicek, W., Ma, M., Bullard, L., Nelson,
S., & Abbeduto, L. (2016). Early language intervention using
distance video-teleconferencing: A pilot study of young boys
with fragile X Syndrome and their mothers. American Journal of
Speech-Language Pathology, 25(1), 46–66.
Olsen, S., Fiechtl, B., & Rule, S. (2012). An evaluation of virtual home
visits in early intervention: Feasibility of “Virtual Intervention.”
The Volta Review, 112(3), 267.
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Weidner, K., & Lowman, J. (2020). Telepractice for adult speech-language
pathology services: A systematic review. SIG 18 Telepractice, 1(1),
326–338. https://doi.org/10.1044/2019_PERSP-19-00146
Woods, J. J., & Brown, J. A. (2011). Integrating family capacity-building
and child outcomes to support social communication develop-
ment in young children with autism spectrum disorder. Topics in
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Woods, J. J., Wilcox, M. J., Friedman, M., & Murch, T. (2011). Col-
laborative consultation in natural environments: Strategies to
enhance family-centered supports and services. Language, Speech,
and Hearing Services in Schools, 42, 379–392.
6 Telepractice
as a Business
Introduction
Starting a business in telepractice is no small undertaking. It is
similar to starting any kind of business but requires additional
steps because of the added complexity of teletherapy. Understand-
ing the steps to start a business and understanding the complexity
of adding telepractice are crucial to running a successful business
(Glaser & Traynor, 2008). With this complexity, laying out the steps to
start a business, and checking them off, assists with ensuring nothing
is missed and the business will be ready to open without hiccups.
With all this said, starting a business is both exciting and scary, exhil-
arating and fearful, and humbling and freeing. It is the best thing an
SLP can do but also very daunting.
As an entrepreneur, one needs to be resilient, organized, per-
sistent, and creative. Having the ability to research what is needed
in order to start a business and asking good questions are necessary
skills. Businesses have many ups and downs so it is important to be
prepared for this variability in income, especially in the early stages
of the business. The SLP needs to have enough reserves in the bank
to survive with minimal income until the practice is bringing in new
clients every day that will provide a steady, predictable income. Being
resilient will take you through the rough times in the business and
help you look forward and make the necessary changes when things
131
132 Telepractice: A Clinical Guide for Speech-Language Pathologists
are not working. SLPs need to be persistent. Persistence will pay off
greatly when they hear a lot of “no’s” or run into brick walls (Green,
2016). This comes in handy when obtaining contracts with schools
and other agencies. Being organized helps with tracking all aspects of
the business including payments, marketing, and tracking client prog-
ress (or lack of progress). Figuring out how to document this informa-
tion and developing (or purchasing) appropriate software-generated
forms will keep the owner organized for both tax and legal purposes.
Creativity is a helpful trait as it can get the business through hard
times. In a recession, many families may no longer be able to afford
speech-language therapy sessions for their loved ones, and this may
impact the SLP’s business, causing caseload and income reduction.
How the business owner works with this reality may provide opportu-
nities for finding creative ways to increase income by looking at other
sources for a period of time. Being creative allows SLPs to market their
practices in unique ways that set them apart from the competition.
Lastly, being able to find the information that is essential to
start a business is critical. Oftentimes, SLPs may post questions on
social media and receive various answers to the same question. This
is because each locality has different requirements for starting a busi-
ness. It is important to research information from the city, county, and
state government’s websites to determine which licenses are needed,
what the costs are, and whether or not the business needs to be reg-
istered in all the planned telepractice localities. These are just some
of the items that need to be completed accurately to avoid legal issues
or tax implications.
The addition of a telepractice model to an existing in-person
practice requires that SLPs understand the legalities, finances, and
intricacies of running a business that requires knowledge about
state licensure laws and regulations, code of ethics (both state and
national), integration into an existing practice, and funding and reim-
bursement. Having good staff support might include an accountant
(CPA), as well as a lawyer to help start the business out on the right
foot. A CPA will help set up an accounting system that will ensure
you are making money; after all, isn’t that why most SLPs go into
private practice? They can assist with setting fees that will ensure you
make a profit. For each individual business, profits will vary depend-
6. Telepractice as a Business 133
ing on personal needs. CPAs can advise the practice on what items
are tax deductible, assist with payroll (if you are not using a payroll
company), and prepare tax returns for your business, as well as your
personal tax returns.
Hiring a lawyer will ensure that the business entity is set up cor-
rectly in the state where the practice is physically located. In addition,
attorneys can assist with legal responsibilities, such as compliance
with Health Insurance Portability and Accountability Act (HIPAA)
regulations, business forms, agreements with employers/contractors,
and contract development with school districts. Although obtaining
a lawyer may seem expensive, it will save the business owner many
headaches, and potentially money, down the road. An attorney can
advise you on employment law and ensure that you have the appro-
priate policies and procedures in place and that they follow the law.
Often, agencies that the business contracts with (e.g., SNFs, hospitals,
school districts, etc.) have their own contracts and it is important
for the SLP’s lawyer to review these contracts to ensure that they are
beneficial to the practice.
Starting a business takes time, energy, and hard work. However,
for most private practitioners, it is the best decision they will ever
make. It allows SLPs the freedom and flexibility to run their business as
they see fit; they can establish workloads that meet their needs which
allows them the freedom to have a work/life balance. If a teletherapy
private practice is something that the SLP has dreamed of, then they are
in the right place to get the information needed to start the business.
The Business Plan
Writing a business plan may seem daunting. However, it is helpful to
look at the business plan as your road map. Without this road map,
you will not know where you are headed, or when you will arrive.
There are two types of business plans: the traditional business plan
and the lean startup. For most SLPs, starting a telepractice business
(unless bank funding or venture capital is needed) the lean business
plan is the easiest to use to lay out your business. It focuses on sum-
134 Telepractice: A Clinical Guide for Speech-Language Pathologists
marizing the basic, most important elements of the plan and does not
take long to complete. In contrast, the traditional business plan has
a standard structure and goes into detail on describing the company,
marketing, financials, revenue streams, key milestones, and so forth,
and can run multiple pages.
The lean startup plan (Table 6–1) is typically one page and lays
out your business, describing the company’s value proposition, struc-
ture, customers and finances (SBA, n.d.). First, choose a name for the
business. Research the business name to ensure that it is not already
being used by another business and that the name is not too similar
to the name of other similar businesses. Many states will require the
business owner to register the name of the company. Names can be
Table 6–1. Lean Startup Business Plan
Company Name
Identity Problem
Our solution Target market
The competition Revenue stream
Marketing activities Expenses
Team and key roles Milestones
Source: https://www.sba.gov/business-guide/plan-your-business/write-your-busi
ness-plan
6. Telepractice as a Business 135
as simple as the SLPs given name and a statement that describes the
mission or values of the company. In thinking about names, it is best
to use a name that is easy to pronounce and memorable. If it is hard to
pronounce or not memorable, potential customers may not be able to
remember it and may be less likely to pronounce it correctly.
The first section in the lean business plan is the Identity of the
business. This is one sentence to describe the business. It should be
written simply, with limited professional jargon and one that family
and friends (who are not in the business) can easily understand. Your
identity is who you are and what you do. For a teletherapy business,
your Identity statement might read something such as, “ABC Tele-
therapy provides speech and language services online for children
birth to 3 years of age.” The statement is simple, indicates services are
via teletherapy, and states the ages that are covered. If the business is
focused on serving individuals with specific disorders or character-
istics, then that would be included.
The next section in the plan states the Problem. When looking
for funding (whether it is a bank loan or venture capital), this section
is very important. Your business should be solving a problem that
potential clients might have in obtaining services. In this case, your
problem might be as follows: “Parents of infants and toddlers are
looking for therapy for their special needs children that is conve-
nient and doesn’t require driving to a location far away from their
home.” The Problem is simply stated and clear, which leads to the
next section, “Our Solution.” In this section, state how you are solving
the problem. As an example: “ABC Teletherapy provides high-quality
speech and language services online whenever and wherever families
are located, with no travel needed.”
Determining the target market for your business is the next step.
The key to determining your target market is to focus somewhat nar-
rowly, initially. The long-term goal of the practice may be to provide
services across the country. However, starting out big may create
more headaches for a new entrepreneur. If the SLP has never owned
a private practice, the learning curve is steep, and to understand the
rules, regulations, and laws in early intervention in all fifty states
could deter even the most persistent entrepreneur. Starting small, as
a new entrepreneur, will allow you to understand the flow of business,
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